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<link href="{$css_path}/modules/systemapi/templates/default/css/print.css" rel="stylesheet" type="text/css" />
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<body style="background-color:#ffffff;">
<div id="wrap_3">
		<div class="title_content_detail">Pre-authorize Transection<br><span style="font-size: 16px; font-family: sarabun;">{$today}</span></div>
		<div id="area_title_description">
			<div class="text_title_description">
					<span class="text_black_title">Pre-auth ID: </span><span class="text_red_title">{$preauthId}</span>
			</div>
			<div class="text_title_images"><img src="{$img_path}/{$img}"></div>
		</div>
		
		<div class="showdetail"><br>
		
			<table width="700" align="center" border="0" cellpadding="0" cellspacing="0" style="font-size:16px; font-family: sarabun;">
				<tr>
					<td class="UnderLine"  colspan="4" align="center"><span class="text_black_bold">ข้อมูลกรมธรรม์</span></td>
				</tr>
				
				<tr>
					<td width="130" align="right">ชื่อผู้เอาประกัน :</td>
					<td width="220">{$policyData.name}&nbsp;&nbsp;{$policyData.surname}</td>
					<td width="130" align="right">บัตรประชาชน : </td>
					<td width="220">{$policyData.natid}</td>
				</tr>
				<tr>
					<td align="right">เลขที่่กรมธรรม์ :</td>
					<td>{$policyData.policy_no}</td>
					<td align="right">เลขที่บัตรประกัน :</td>
					<td>{$policyData.cardno}</td>
				</tr>
				<tr>
					<td align="right">วันเริ่มคุ้มครอง :</td>
					<td>{$policyData.effective}</td>
					<td align="right">วันสิ้นสุดความคุ้มครอง :</td>
					<td>{$policyData.expiry}</td>
				</tr>
				<tr>
					<td align="right">แผนความคุ้มครอง :</td>
					<td>{$policyData.plan}</td>
					<td align="right">&nbsp;</td>
					<td>&nbsp;</td>
				</tr>
				<tr>
					<td align="right">OPD :</td>
					<td>{$PlanData.opd}</td>
					<td align="right">ER :</td>
					<td>{$PlanData.er}</td>
				</tr>
				<tr>
					<td align="right">OPD คงเหลือ :</td>
					<td>{$PlanData.opdremain}</td>
					<td align="right">R&B :</td>
					<td>{$PlanData.rb}</td>
				</tr>
				<tr>
					<td align="right"><span style="font-size: 20px; color: #000000; font-weight: bold;">สถานะกรมธรรม์ :</span></td>
					<td><span style="font-size: 20px; color: '.$polstatus_color.'; font-weight: bold;">{$policyData.polstatus_desc}</span></td>
					<td align="right">&nbsp;</td>
					<td>&nbsp;</td>
				</tr>
			</table>
								
			<table width="700" align="center" border="0" cellpadding="0" cellspacing="0" style="font-size:16px; margin-top:5px;" >
				<tr>
					<td align="center" valign="top">
						<table width="350" align="center" border="1" cellpadding="0" cellspacing="0" height="100%" >
							<tr>
								<td class="UnderLine2" align="center" ><span class="text_black_bold">เงื่อนไขกรมธรรม์</span></td>
							</tr>
							<tr>
								<td  height="300" align="left" valign="top">{$paInfo.policy_condition}</td>
							</tr>
						</table>
					</td>
					<td  align="center" valign="top">
						<table width="350" align="center" border="1" cellpadding="0" cellspacing="0" height="100%" >
							<tr>
								<td class="UnderLine2" align="center" ><span class="text_black_bold">Exclusion</span></td>
							</tr>
							<tr>
								<td height="300" width="100%" align="left" valign="top">{$policyData.exclusion}</td>
							</tr>
						</table>
					</td>
				</tr>
			</table>
			
			<table width="700" align="center" border="0" cellpadding="0" cellspacing="0" style="font-size:16px; margin-top:15px;" >
				<tr>
					<td  align="center" valign="top">
						<table width="350" align="center" border="1" cellpadding="0" cellspacing="1" height="150">
							<tr>
								<td colspan="3" class="UnderLine2" align="center"><span class="text_black_bold">ประวัติการรักษา(ER/*{$PlanData.er}*/)</span></td>
							</tr>
							<tr>
								<td class="UnderLine3" width="33%" align="center" valign="bottom">วันเกิดอุบัติเหตุ</td>
								<td class="UnderLine3" width="33%" align="center" valign="bottom">ค่าใช้จ่าย</td>
								<td class="UnderLine3" width="33%" align="center" valign="bottom">ICD10</td>
							</tr>
	
							{foreach from = $erClaimData item=er}
								<tr>
									<td align="center">{$er.acc_date}</td>
									<td align="center">{$er.paid} บาท</td>
									<td align="center">{$er.diags}</td>
								</tr>
							{/foreach}
						</table>
					</td>
					<td   align="center" valign="top">
						<table width="350" align="center" border="1" cellpadding="0" cellspacing="1" height="150">
							<tr>
								<td colspan="3" class="UnderLine2" align="center"><span class="text_black_bold">ประวัติการรักษา(OPD)</span></td>
							</tr>
							<tr>
								<td class="UnderLine3" width="33%" align="center" valign="bottom">วันเข้ารับการรักษา</td>
								<td class="UnderLine3" width="33%" align="center" valign="bottom">โรงพยาบาล</td>
								<td class="UnderLine3" width="33%" align="center" valign="bottom">ICD10</td>
							</tr>
							{foreach from = $OPDClaimData item = value}
								<tr>
									<td align="center">{$value.acc_date}</td>
									<td align="center">{$value.paid}</td>
									<td align="center">{$value.diags}</td>
								</tr>
							{/foreach}
						</table>
					</td>
				</tr>
			</table>
		
			<table width="700" align="center" border="0" cellpadding="3" cellspacing="0" style="font-size:16px; margin-top:15px;" >
				<tr>
					<td width="700" height="130" align="center" valign="top">
						<table width="650" align="center" border="0" cellpadding="3" cellspacing="0" height="90" >
							<tr>
								<td colspan="3" class="UnderLine2" align="center"><span class="text_black_bold">บันทึกเกี่ยวกับ ผอป.</span></td>
							</tr>
							<tr>
								<td  colspan="3" align="center" valign="bottom">{$paInfo.note2hosp}</td>
							</tr>
						</table>
					</td>
				</tr>
			</table>		
	</div>
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